What costs four hundred dollars and has to be bought 24 times a year?
Insulin.

[Title Card: Insuline Glargine]
[Cite "The Evolution of Insulin Glargine..."?]

Diabetes has been written about since the ancient Egyptians, with the
first known description written in 1500 BC and named in 230 BC.
It was known natively as "pissing evil" because it was characterized by
frequent urination followed by death.
And that's about all philosophers understood about the disease until the
late 19th century.
Insulin is the key to diabetes, medically, 

[https://www.etymonline.com/word/diabetes]

After one laboratory discovered the link between an injured pancreas and
diabetes by performing a full pancreatectomy, there launched a
three-decade search for a way to isolate the substance in the pancreas
keeping the dogs alive.
Various scientists tried extracting the essence by soaking raw pancreas
in solutions of saltwater, alcohol, cold water, hot water, and several
acids, but these all had the same problem: the production was toxic.
Four University of Toronto scientists, Banting, Best, McCloud, Collip
shared two Nobels for the development of a manufacturing process: slowly
inject another hormone, secretin, into a cow's pancreas, and then soak
the pancreas in solution.
The patent was sold to the University of Toronto for one dollar so that
drug companies wouldn't create dangerous knockoffs and patent those to
gain monopoly.
According to *The discovery of insulin,* the scientists wrote a joint
letter saying:
    The patent would not be used for any other purpose than to prevent
    the taking out of a patent by other persons. When the details of the
    method of preparation are published anyone would be free to prepare
    the extract, but no one could secure a profitable monopoly.
[https://en.wikipedia.org/wiki/Insulin#cite_note-134]

The university licensed the right to produce insulin to Eli Lilly and a
dozen other companies for free, hoping that insulin could help as many
people as possible, allowing the companies to patent discoveries about
manufacturing and other improvements.
Animal insulin from pigs and cows is a "bolus" insulin, meaning that
it's meant to be injected before meals or infused continuously because
it peaks and dissipates quickly.
Neutral protamine Hagedorn (NPH) complemented it by slowing down
absorption of insulin, allowing diabetics to take fewer shots, but it
also was the first major patent encumbrance, in 1946.
Other innovations like lente insulin in the 50s, purification processes
for safer insulin in the 70s, all carried with their own patents,
ensuring that generic companies couldn't set up shop.
But during this time, there is a remarkable anti-monopoly feeling: since
the Roosevelt days, both Teddy and Franklin, Americans rallied against
mergers and patent monopolies because competition was the prevailing
ethos.

[Cite "Why is there no generic insulin?"]

[https://www.healthline.com/diabetesmine/history-of-insulin-costs]

[Section: Reagan and Synthetic Insulin]

In the 1980s, synthetic human insulin was developing, and so was
Reagan's monopoly strategy.
Insulin is a protein---a biological machine that is programmed by a
"gene" in DNA.
Specifically, it's a hormone: it "plugs in" to a detector on the outside
of a cell and tells it to use more energy by consuming more sugar.
Remarkably, the genetic language for proteins is understood by every
living thing, so the gene can be taken out of humans and spliced into
bacteria, and describe the exact same structure.
Like bovine and porcine insulins, human insulin is a "bolus" and only
lasts for about 8 hours.
An NPH version of human insulin was created, too, to create a basal
version.
Still, there is evidence that NPH is less safe because it peaks
inconsistently, making it harder to manage blood sugar.
Genetic engineering is very powerful, and a new class of insulins was
invented: ultralongs.
With no peak and a 36 hour duration, insulin glargine, also called
Lantus or Toujeo (made by Sanofi) or Basaglar (started by Eli Lilly in
2015), was patented in 2000, continuing the patent monopolies until
2027.

Reagan helped create the companies the companies that made these drugs,
and his lasting influence on American politics keeps them there.
Reagan was outright pro-monopoly, believing that the failures of America
to compete internationally aren't because bloated industries are being
blindsided by, for example, Japanese manufacturers, but rather those
industries don't have enough concentrated power to respond.
President Reagan's Justice Department asserted that, to prevent a
merger, the court must be certain of its harmful effect.
From 1980 to 1984, the number of annual mergers doubled.

[cite https://www.multinationalmonitor.org/hyper/issues/1986/0215/

From 1995 to 2015, 60 pharma companies merged into just 10, including
Sanofi, manufacturer of insulin glargine, that now maintains a 42
billion dollar revenue year-to-year.

[cite the fantastic openmarketsinstitute.org one]

Patents, too: they are intended to reward creativity with a temporary
monopoly, but before the Reagan era, patents were seen as a potential
danger: if a company gets too many or abuses what they have, they might
get broken up or fined.
But while the pharma corporations were developing this fiscal monopoly,
the Rehnquist Court was redefining patents as a declaration, by the
United States, of a "legitimate monopoly."

[cite nber]

Worse yet, the FDA regulations that make the industry safe makes
redeveloping generic versions extremely costly, and when they do,
corporations can just pay them off.

[cite https://www.openmarketsinstitute.org/learn/drug-prices-monopoly]

[Section: The profit motive]

But glargine's a bittersweet victory.
Glargine costs about seven dollars to manufacture ten
milliliters, but Sanofi, Lantus's manufacturer, lists it for 375.
Even for people with insurance, this can still cost 50 dollars in
copay---for something that needs to be refilled 24 times a year.
The FDA-approved early-launch alternative, Basaglar, is 165 for the same
amount, but it's the *one* alternative, launched by another insulin
giant, Eli Lilly.
Affordable insulin relies on precarious manufacturer rebates and full
employment, but even with these preconditions, 25% of patients report
trying to "stretch" their insulin---probably because the average
diabetic pays twenty thousand per year for medical care.

But how did they get this position?
Last year, Sanofi spent four million dollars on lobbying.
Eli Lilly spent seven million.
PhRMA, the industry lobbying group that both are members of: 29 million.
Government-granted patent monopolies drive up prices for everyone,
to the exclusive benefit of ten massive multinationals.
Eli Lilly, Sanofi, and Merck, another pharma company trying to get in on
the glargine action, spend 6 billion each on R&D, but who paid for it?
The US government.
Americans' government subsidizes the majority of basic research done by
pharmaceutical companies, yet the pharmaceutical companies are still
allowed to utterly exploit their subjects.

[https://go.gale.com/ps/retrieve.do?tabID=Journals&resultListType=RESULT_LIST&searchResultsType=MultiTab&hitCount=6&searchType=BasicSearchForm&currentPosition=2&docId=GALE%7CA101569966&docType=Article&sort=Relevance&contentSegment=ZICC-MOD1&prodId=CSIC&pageNum=1&contentSet=GALE%7CA101569966&searchId=R2&userGroupName=gainstoftech&inPS=true%2Chttps%3A%2F%2Fgaleapps.gale.com%2Fapps%2Fauth]

Everyone, on the right and on the left, agrees that the rapidly
inflating drug prices are hurting Americans, but it's still happening.

[Insert news headline of https://www.cnn.com/2020/05/26/politics/white-
house-insulin-cap-medicare/index.html]
[And https://www.statnews.com/2020/01/28/insulin-pricing-becomes-top-
issue-for-democrats/]


[Image: https://upload.wikimedia.org/wikipedia/commons/thumb/f/f2/
Insulin_short-intermediate-long_acting.svg/2000px-Insulin_short-
intermediate-long_acting.svg.png (graph of insulin stuff)]
[Image of insulin vial from Wikipedia]